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2022 Medicare Advantage Plan Benefit Details for the Health Net Jade (HMO SNP)

2022 Medicare Advantage Plan Details
Medicare Plan Name:Wellcare Specialty No Premium (HMO C-SNP)
Location:Kern, California
Plan ID:H0562 - 092 - 0     Click to see other plans
Member Services:1-800-275-4737 TTY users 711
— Enrollment Options —
Medicare Contact Information:1-800-MEDICARE (1-800-633-4227)
TTY users 1-877-486-2048
Speak to a licensed sales agent to learn more and enroll.
Call Medicare Solutions at 855-373-9484 / TTY 711

Monday ‐ Friday 8:30am — 10pm EST
Email a copy of the Wellcare Specialty No Premium (HMO C-SNP) benefit details
— Medicare Plan Features —
Monthly Premium:$0.00 (see Plan Premium Details below)
Annual Deductible:$0
Annual Initial Coverage Limit (ICL):$4,430
Health Plan Type:Local HMO
Special Needs Plan (SNP)
Eligibility Requirement:
Cardiovascular Disorders, Chronic Heart Failure and Diabetes
Additional Gap Coverage?No additional gap coverage, only the Donut Hole Discount
Total Number of Formulary Drugs:3,383 drugsBrowse the Wellcare Specialty No Premium (HMO C-SNP) Formulary
This plan has 6 drug tiers. See cost-sharing for all pharmacies and tiers
This plan offers select insulin at a $0 copay. Learn more.
Formulary Drug Details:Tier 1Tier 2Tier 3Tier 4Tier 5
Preferred Pharmacy
  Cost-Sharing during
  initial coverage phase:
Number of Drugs per
Plan's Pharmacy Search:http://ca.healthnetadvantage.com/prescription-drugs-formulary/find-a-pharmacy
Plan Offers Mail Order?Yes
Number of Members enrolled in this plan in Kern, California:1,706 members
Number of Members enrolled in this plan in (H0562 - 092):5,023 members
Plan’s Summary Star Rating: 4 out of 5 Stars.
Customer Service Rating: 5 out of 5 Stars.
Member Experience Rating: 3 out of 5 Stars.
Drug Cost Accuracy Rating: 4 out of 5 Stars.
— Plan Premium Details —
The Monthly Premium is Split as Follows:
Part C
Part D Base
Part D Supplemental
Monthly Premium with Extra Help Low-Income Subsidy (LIS): 100%
Monthly Part D Premium with LIS:$0.00$0.00$0.00$0.00
Total Monthly Premium with LIS (Parts C & D):$0.00$0.00$0.00$0.00
— Plan Health Benefits —
** Base Plan **
• Health plan premium: $0
• Drug plan premium: $0
• You must continue to pay your Part B premium.
• Part B premium reduction: No
• Health plan deductible: $0
• Other health plan deductibles: In-network: No
• Drug plan deductible: No annual deductible
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
• $1
Optional supplemental benefits
• No
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
• In-network: No
Doctor visits
• Primary: $0 copay
• Specialist: $0 copay (authorization and referral required)
Diagnostic procedures/lab services/imaging
• Diagnostic tests and procedures: $0 copay (authorization required)
• Lab services: $0 copay (authorization required)
• Diagnostic radiology services (e.g., MRI): $0 copay (authorization and referral required)
• Outpatient x-rays: $0 copay (authorization and referral required)
Emergency care/Urgent care
• Emergency: $120 copay per visit (always covered)
• Urgent care: $0 copay
Inpatient hospital coverage
• $0 per day for days 1 through 90 (authorization and referral required)
Outpatient hospital coverage
• $0 copay (authorization and referral required)
Skilled Nursing Facility
• $0 per day for days 1 through 20
$50 per day for days 21 through 100 (authorization required)
Preventive care
• $0 copay
Ground ambulance
• $40 copay
Rehabilitation services
• Occupational therapy visit: $0 copay (authorization and referral required)
• Physical therapy and speech and language therapy visit: $0 copay (authorization and referral required)
Mental health services
• Inpatient hospital - psychiatric: $900 per stay (authorization required)
• Outpatient group therapy visit with a psychiatrist: $25 copay (authorization required)
• Outpatient individual therapy visit with a psychiatrist: $25 copay (authorization required)
• Outpatient group therapy visit: $25 copay (authorization required)
• Outpatient individual therapy visit: $25 copay (authorization required)
Opioid treatment program services
• In-network: $0.00 copay (authorization required)
Medical equipment/supplies
• Durable medical equipment (e.g., wheelchairs, oxygen): 20% coinsurance per item (authorization required)
• Prosthetics (e.g., braces, artificial limbs): 20% coinsurance per item (authorization required)
• Diabetes supplies: $0 copay (authorization required)
• 20% coinsurance (referral required)
• Hearing exam: $0 copay (authorization required)
• Fitting/evaluation: $0 copay (limits apply, authorization required)
• Hearing aids: $0 copay (limits apply, authorization required)
Preventive dental
• Oral exam: $0 copay (limits apply, authorization required)
• Cleaning: $0 copay (limits apply, authorization required)
• Fluoride treatment: $0 copay (limits apply, authorization required)
• Dental x-ray(s): $0 copay (limits apply, authorization required)
Comprehensive dental
• Non-routine services: $0 copay (authorization required)
• Diagnostic services: $0-15 copay (authorization required)
• Restorative services: $0-300 copay (authorization required)
• Endodontics: $5-275 copay (authorization required)
• Periodontics: $0-375 copay (limits apply, authorization required)
• Extractions: $15-150 copay (authorization required)
• Prosthodontics, other oral/maxillofacial surgery, other services: $0-2 (authorization required)
• Routine eye exam: $0 copay (limits apply, authorization required)
• Other: Not covered
• Contact lenses: $0 copay (limits apply, authorization required)
• Eyeglasses (frames and lenses): $0 copay (limits apply, authorization required)
• Eyeglass frames: $0 copay (limits apply, authorization required)
• Eyeglass lenses: $0 copay (limits apply, authorization required)
• Upgrades: $0 copay (limits apply, authorization required)
Medically-approved non-opioid pain management services
• Chiropractic services: Not covered
• Acupuncture: Some coverage
• Therapeutic Massage: Not covered
• Alternative Therapies: Not covered
More benefits
• Transportation services: Some coverage
• Transportation services for non-emergency care: Plan-approved locations: Not covered
• Over-the-counter drug benefits: Some coverage
• Meals for short duration: Not covered
• Annual physical exams: Some coverage
• Telehealth: Some coverage
• WorldWide emergency coverage: Some coverage
• WorldWide emergency urgent care: Some coverage
• Fitness Benefit: Some coverage
• In-Home Support Services: Not covered
• Bathroom Safety Devices: Not covered
• Health Education: Not covered
• In-Home Safety Assessment: Not covered
• Personal Emergency Response System (PERS): Not covered
• Medical Nutrition Therapy (MNT): Not covered
• Post discharge In-Home Medication Reconciliation: Not covered
• Re-admission Prevention: Not covered
• Wigs for Hair Loss Related to Chemotherapy: Not covered
• Weight Management Programs: Not covered
• Adult Day Health Services: Not covered
• Nutritional/Dietary Benefit: Some coverage
• Home-Based Palliative Care: Not covered
• Support for Caregivers of Enrollees: Not covered
• Additional Sessions of Smoking and Tobacco Cessation Counseling: Some coverage
• Enhanced Disease Management: Not covered
• Telemonitoring Services: Not covered
• Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline): Some coverage
• Counseling Services: Some coverage
Wellness programs (e.g., fitness, nursing hotline)
• Covered
• $0 copay (limits apply, authorization required)
Foot care (podiatry services)
• Foot exams and treatment: $0 copay (referral required)
• Routine foot care: $0 copay (limits apply, referral required)
Medicare Part B drugs
• Chemotherapy: 20% coinsurance (authorization required)
• Other Part B drugs: 20% coinsurance (authorization required)

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Tips & Disclaimers
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
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  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDP-Compare.com and MA-Compare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
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  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.